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bv/sb/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzd Sanlmn / M / 60 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the RLE since 4-5 days.

EXAMINATION :

M.R.I of the lumbo-sacral spine was performed using the following parameters :

5 mm thick T1 Weighted and T2 Weighted sagittal images.

5 mm thick T1 Weighted and T2 Weighted axial images.

OBSERVATION :

There is loss of water content of all the lumbar intervertebral discs.

There is a postero-central disc protrusion at the L5-S1 level with ventral indentation upon the thecal sac. Far lateral disc bulges are also seen at this level.

There is a right far lateral (extraforaminal) disc herniation at the L4-L5 level with indentation upon the foraminal and extraforaminal portion of the right L4 nerve root.

A posterior disc bulge is seen at the L3-L4 level.

A right paracentral disc herniation with posterior peridiscal osteophyte is seen at the L2-L3 level with ventral indentation of the thecal sac. A right postero-lateral (foraminal) disc herniation is also seen at this level narrowing the right neural foramen.

A right posterior peridiscal osteophyte with a disc herniation is seen at the L1-L2 level with ventral indentation of the thecal sac.
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Small posterior peridiscal osteophytes are noted at the L3-L4, L4-L5 and L5-S1 levels.

The facet joint at the L5-S1, L4-L5, L3-L4 and L1-L2 level on the left side shows hypertrophic degenerative changes.

Anterior disc herniations are noted in the lumbar region at the L1-L2, L2-L3 and L3-L4 levels.

Schmorls nodes are seen in the L3 and L4 vertebrae inferiorly.

Focal hypointense areas on the T1 Weighted images which are seen to turn hyperintense on the T2 Weighted images in the L3, L4, L5 vertebrae are of ? significance.

The rest of the lumbar vertebral bodies reveal normal signal intensity. The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.

A probable conjoint nerve root is noted at the L5-S1 level on the left.

The conus medullaris terminates at the L1 level and the thecal sac terminates at the S2 level.

The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :

13.0 mm at L1-L2
13.0 mm at L2-L3
14.0 mm at L3-L4
12.0 mm at L4-L5
11.0 mm at L5-S1.

IMPRESSION :

The MRI features are suggestive of :

1. A right far lateral (extraforaminal) disc herniation at the L4-L5 level with indentation upon the foraminal and extraforaminal portion of the right L4 nerve root.
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- 3 - scan-00005


2. A right paracentral disc herniation with posterior peridiscal osteophyte at the L2-L3 level with a right postero-lateral (foraminal) disc herniation at this level.

3. A right posterior peridiscal osteophyte with a disc herniation at the L1-L2 level.

4. Small posterior peridiscal osteophytes at the L3-L4, L4-L5 and L5-S1 levels.

5. Hypertrophic facetal arthropathy at the L5-S1, L4-L5, L3-L4 and L1-L2 levels on the left side.







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